DR -4420 Documentation Submission/Reimbursement Request (Public Assistance)

Applicant Name*

Name of Person Submitting Documentation*

E-Mail Address*

Phone Number

(best phone number to reach the person submitting this request)

Claim Information

Project Number*

(Only submit one project per request)

Total Claim Amount Requested*

This request is...*

Select or enter value

Submission Date*

Documentation Submission

Please include NEMA's "Request for Reimbursement Form" to summarize all costs being submitted (large projects only). This form is located at: https://nema.nebraska.gov/recovery/fema-4420-dr-nebraska-severe-winter-storm-straight-line-winds-and-flooding (on the far right side) Please Include all invoices, timesheets, proof of payment, procurement information and applicable permitting documentation with your request. If you have any questions prior to submission or need assistance with your request- contact nema.publicassistance@nebraska.gov